Ischemic Colitis in a Non-High-Risk Patient: A Case of Diagnostic Oversight

Samir Barakeh^*
*Correspondence: Samir Barakeh, Department of Special Surgery, Bulgaria, Email:

Introduction

Ischemic Colitis (IC) is a condition characterized by inflammation and injury to the colon due to a reduction in blood flow, which can lead to varying degrees of ischemic damage. While it is most commonly seen in elderly individuals or those with cardiovascular risk factors such as atherosclerosis, heart failure, or atrial fibrillation, ischemic colitis can also occur in younger, otherwise healthy individuals. In these patients, the diagnosis can be more challenging due to the lack of traditional risk factors, potentially leading to delayed or missed diagnoses. Symptoms of ischemic colitis typically include abdominal pain, bloody diarrhea, and changes in bowel habits, which can be mistaken for other gastrointestinal conditions, making it important for clinicians to maintain a broad differential diagnosis. This case report discusses a nonhigh- risk patient who developed ischemic colitis, highlighting the potential for diagnostic oversight when classic risk factors are absent. The case underscores the need for clinicians to consider ischemic colitis in patients with unexplained gastrointestinal symptoms, regardless of their cardiovascular history. It also emphasizes the importance of timely diagnosis and intervention, as ischemic colitis can lead to serious complications such as bowel necrosis, perforation, and sepsis if not recognized early. Through this case, we aim to raise awareness about ischemic colitis in low-risk populations and encourage a higher level of suspicion to avoid misdiagnosis and optimize patient outcomes [1].

Description

Ischemic Colitis (IC) is a gastrointestinal condition that results from reduced blood flow to the colon, leading to inflammation and potential injury of the affected tissue. Typically, ischemic colitis occurs in individuals who are older or have underlying vascular risk factors, such as atherosclerosis, heart disease, atrial fibrillation, or those with a history of shock, sepsis, or recent abdominal surgery. However, ischemic colitis can also occur in patients without these typical risk factors, and in these cases, the diagnosis can be challenging, often leading to delays or misdiagnosis. This is particularly concerning given the potential severity of the condition, which can progress to complications such as bowel necrosis, perforation, and sepsis if not recognized and treated promptly. In the case of non-high-risk patients, ischemic colitis may not be immediately suspected because the classic risk factors are absent. As a result, initial clinical evaluations may focus on more common gastrointestinal conditions, such as infectious colitis, inflammatory bowel disease, or diverticulitis, leading to a delay in the correct diagnosis. Symptoms of ischemic colitis typically include acute onset of lower abdominal pain, often accompanied by diarrhea or bloody stools. The pain can be severe and is often out of proportion to the clinical findings on physical examination. In many cases, patients may not exhibit the classic signs of vascular compromise or systemic illness, which can further complicate the diagnostic process. In a non-high-risk patient, the absence of the typical cardiovascular risk factors should not rule out ischemic colitis. Other factors, such as a transient decrease in blood flow (e.g., due to low blood pressure, dehydration, or vasoconstriction), can contribute to ischemic injury in the colon even in the absence of significant underlying cardiovascular disease. These factors may be less immediately obvious but are crucial to consider in the clinical workup of a patient presenting with unexplained abdominal pain and gastrointestinal distress. In some cases, ischemic colitis may be triggered by factors like acute infections, medications (such as vasopressors or chemotherapy agents), or even a sudden increase in intra-abdominal pressure, all of which may occur in individuals without traditional risk factors for ischemic injury [2]. When ischemic colitis occurs in a non-high-risk patient, it may present as an acute, self-limited illness, with symptoms improving after supportive treatment in some cases. However, in others, the disease can progress rapidly, with complications like bowel necrosis or perforation that require urgent surgical intervention. Therefore, prompt recognition of ischemic colitis is crucial for preventing severe outcomes. A high index of suspicion is needed, and clinicians should consider performing imaging studies, such as a contrast-enhanced CT scan, which can reveal thickening of the colonic wall, pneumatosis, or signs of bowel ischemia. Colonoscopy may also be helpful in diagnosing ischemic colitis, as it can show areas of mucosal pallor, cyanosis, or even ulceration, which are characteristic of the condition. The treatment of ischemic colitis in a non-high-risk patient typically involves supportive care, including fluid resuscitation, bowel rest, and correction of any underlying factors contributing to the ischemia, such as dehydration, low blood pressure, or medication adjustments. In cases of severe ischemia or when complications arise, surgical intervention may be necessary to remove necrotic bowel tissue and prevent life-threatening conditions like sepsis. Despite its potential for significant morbidity, the prognosis for ischemic colitis can be favorable when the diagnosis is made early and appropriate management is initiated. However, delays in diagnosis, particularly in non-high-risk individuals, can lead to worsened outcomes and the need for more invasive treatment [3]. Ischemic colitis (IC) is typically associated with high-risk factors such as advanced age, cardiovascular disease, atherosclerosis, or other comorbidities that compromise blood flow to the colon. However, the diagnosis of ischemic colitis in a non-high-risk patient presents a unique challenge and can often be overlooked or misdiagnosed, leading to delayed treatment and potentially serious complications. A case of ischemic colitis in a non-high-risk patient underscores the importance of maintaining a broad differential diagnosis and considering ischemic causes of gastrointestinal symptoms even in the absence of traditional risk factors. In this case, a previously healthy middle-aged patient presented with acute abdominal pain, bloating, and bloody diarrhea, which were initially attributed to a more common condition such as gastroenteritis or diverticulitis. Despite the patient's lack of typical risk factors for ischemic colitis such as history of cardiovascular disease, smoking, or previous abdominal surgery the severity and persistence of symptoms prompted further investigation. Imaging studies and subsequent colonoscopy revealed areas of colonic ischemia, confirming the diagnosis of ischemic colitis [4]. This case illustrates that ischemic colitis should be considered in any patient presenting with abdominal pain and gastrointestinal distress, regardless of age or comorbidity status. While the condition is more commonly seen in high-risk populations, non-high-risk patients may also develop ischemic colitis due to other factors, such as transient hypotension, dehydration, use of certain medications or hypercoagulable states. The diagnosis of ischemic colitis requires a high index of suspicion and timely diagnostic workup, including abdominal imaging and colonoscopy to assess for characteristic findings like mucosal edema, erythema, and hemorrhagic patches. Management of ischemic colitis in non-high-risk patients generally involves conservative treatment, including bowel rest, hydration, and supportive care. However, in cases where ischemia is more severe or complications like perforation or gangrene occur, surgical intervention may be necessary. Early recognition and prompt intervention are crucial to improving outcomes and preventing long-term complications such as bowel necrosis or chronic gastrointestinal dysfunction. This case highlights the importance of not dismissing less common diagnoses based solely on the absence of typical risk factors. Even in low-risk patients, ischemic colitis should be considered when clinical presentation and symptoms suggest gastrointestinal compromise. By maintaining a broad differential and applying appropriate diagnostic tools, healthcare providers can reduce the risk of diagnostic oversight and ensure timely, effective treatment for all patients [5].

Conclusion

This case report highlights the importance of maintaining a broad differential diagnosis when evaluating patients with abdominal pain and gastrointestinal symptoms, especially in individuals without known cardiovascular risk factors. It underscores that ischemic colitis should be considered in any patient with acute abdominal pain and gastrointestinal symptoms, regardless of their overall risk profile. Clinicians should remain vigilant and aware of the potential for ischemic injury in the colon, as early recognition and intervention can significantly improve outcomes and reduce the risk of serious complications. By raising awareness of ischemic colitis in non-high-risk populations, this case aims to encourage more timely and accurate diagnoses and ultimately improve the care of patients with this condition.

References

1. Cruz, Cinthia, Hani H. Abujudeh, Rosalynn M. Nazarian and James H. Thrall. "Ischemic colitis: Spectrum of CT findings, sites of involvement and severity." Emerg Radiol 22 (2015): 357-365.

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2. Yngvadottir, Y., B. R. Karlsdottir, J. P. Hreinsson and G. Ragnarsson, et al. "The incidence and outcome of ischemic colitis in a population-based setting." Scand J Gastroenterol 52 (2017): 704-710.

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